What is the management plan for Upper Gastrointestinal (UGI) bleeding in patients taking Nimesulide (Nimesulide is a Nonsteroidal Anti-Inflammatory Drug (NSAID))?

Management of Upper Gastrointestinal Bleeding in Patients Taking Nimesulide

Immediately discontinue nimesulide, initiate resuscitation with crystalloids if hemodynamically unstable, start high-dose intravenous PPI therapy, and perform endoscopy within 24 hours with endoscopic hemostasis for high-risk stigmata, followed by at least 72 hours of hospitalization for high-risk patients. 1

Immediate Resuscitation and Initial Management

• Initiate fluid resuscitation with crystalloids in patients with hemodynamic instability to restore end-organ perfusion 2, 3
• Transfuse blood if hemoglobin <80 g/L in patients without cardiovascular disease; use a higher threshold for those with cardiovascular disease 1
• Discontinue nimesulide immediately as NSAIDs are a major cause of peptic ulcer bleeding and continuing therapy increases rebleeding risk 1

Risk Stratification

• Use Glasgow Blatchford score ≤1 to identify very low-risk patients who may not require hospitalization or inpatient endoscopy 1
• Consider nasogastric tube placement in selected patients as findings have prognostic value, with bright blood being an independent predictor of rebleeding 1, 3
• High-risk features include hemodynamic instability, melena, fresh red blood in emesis, and elevated urea or creatinine 3

Pharmacologic Management

• Start intravenous PPI therapy immediately upon presentation, before endoscopy 1, 2, 3
• Pre-endoscopic PPI therapy may downstage the lesion and decrease need for endoscopic intervention but should not delay endoscopy 1
• After successful endoscopic hemostasis for high-risk stigmata, use PPI via intravenous loading dose followed by continuous infusion for 3 days (strong recommendation, moderate-quality evidence) 1
• Following 3 days of high-dose IV PPI, continue with twice-daily oral PPI through 14 days, then once daily 1
• Do NOT use H2-receptor antagonists for acute ulcer bleeding 1
• Do NOT routinely use somatostatin or octreotide for acute ulcer bleeding 1

Endoscopic Management

• Perform endoscopy within 24 hours of presentation 1, 2
• Endoscopic hemostasis is indicated for high-risk stigmata (active bleeding or visible vessel in ulcer bed) 1
• Use combination therapy: thermocoagulation or sclerosant injection with clips (strong recommendation) 1
• Epinephrine injection alone is NOT recommended; it must be combined with another method 1
• For adherent clots, attempt targeted irrigation to dislodge, then treat underlying lesion 1
• Endoscopic therapy is NOT indicated for low-risk stigmata (clean-based ulcer or flat pigmented spot) 1

Post-Endoscopic Care

• Hospitalize high-risk patients for at least 72 hours after endoscopic hemostasis 1, 2
• Low-risk patients can be fed within 24 hours after endoscopy 1
• Test all patients for Helicobacter pylori and provide eradication therapy if present, with confirmation of eradication 1
• Repeat negative H. pylori tests obtained during acute bleeding, as false-negative rates are increased in the acute setting 1, 3

Management of Failed Endoscopic Therapy

• Seek surgical consultation for patients in whom endoscopic therapy has failed 1
• Consider percutaneous embolization as an alternative to surgery where available 1
• Repeat endoscopic therapy is recommended for recurrent bleeding 2, 3

Secondary Prevention After NSAID-Induced Bleeding

This is critical as nimesulide caused the initial bleed:

• If NSAID is absolutely required, recognize that traditional NSAID plus PPI OR COX-2 inhibitor alone still carries clinically important rebleeding risk 1
• The combination of PPI plus COX-2 inhibitor is recommended to reduce recurrent bleeding risk beyond COX-2 inhibitor alone 1
• Consider misoprostol 200 mcg four times daily with food as an alternative gastroprotective agent for high-risk patients requiring NSAIDs 4
• Avoid nimesulide and other NSAIDs if possible in patients with history of ulcer complications (very high-risk category) 1

Common Pitfalls

• Do not perform routine second-look endoscopy; it is only useful in selected high-risk patients 1, 3
• Do not delay endoscopy in patients receiving anticoagulants 1
• Do not use promotility agents routinely before endoscopy 1
• Recognize that concomitant corticosteroids increase NSAID bleeding risk with an incidence rate ratio of 12.8 and excess risk of 5.5 5
• Be aware that SSRIs combined with NSAIDs produce significant excess bleeding risk (RERI 1.6) 5
• Non-adherence to gastroprotective therapy increases UGI event risk 2.4-fold, emphasizing the importance of patient education about medication adherence 6